HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 36 BEAVER BROOK ROAD 4/3/2025 Tow.. of North Andover
<LN Commonwealth of Massachusetts
City/Town of No Andover MAY 5 2025
System Pumping Record
Form 4
Helt*:�Lh DepartmIt n t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15,351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
2L
use only the tab ,' pet,
key to move your Address
cursor-do not
use the return —State ------------ Zip_Code__"- _"___
key.
2. System Owner:
Address(if different from
No Andover MA Zip—Code --
City/Town State
Telephone Number
B. Pumping' Record
2
,or
2. Quantity Pumped: G s
1. Date of Pumping Dalion
3. Component: Cesspool(s) /l/Septic Tank ❑ Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? [j Yes /No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. System Pu d B
C
Name Vehicle License Number
'Stewart's Sep�ic58 So Kimball St. , BraqforqMA
Company__
7. Location where contents were disposed:
20 SoMill St.,Br c1forcl W
LJ 3,
Date
er
Signature of Receiving Facility(or attach facility receipt) Date
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